The efficacy of thoracoscopic fissureless lobectomy in patients with dense fissures

Abstract

Background: Prolonged air leakage after a lobectomy remains a frequent complication in patients with dense fissures. To avoid postoperative air leakage, we used the "thoracoscopic fissureless technique" for patients with dense fissures. A thoracoscopic approach is useful for the fissureless technique because it gives a good operative view from various angles without dividing the fissure. In this study, we compared the perior intraoperative results of thoracoscopic fissureless lobectomies to traditional lobectomies with fissure dissection for pulmonary artery (PA) exposure in order to identify the efficacy of thoracoscopic fissureless lobectomy.Methods: Between April 2012 and November 2015, 175 patients underwent a thoracoscopic lobectomy with three or four ports, of whom 14 underwent a fissureless lobectomy because of dense fissures. We compared the characteristics and perioperative outcomes of the patients who underwent the fissureless technique (fissureless technique group, n=14) and the traditional fissure dissection technique for PA exposure (traditional technique group, n=161). In our department, fissureless lobectomy is indicated for patients with a fused fissure (fissural grade III or IV as proposed by Craig in 1997) or inflammation makes it difficult to expose the PA, while the traditional technique is used for other patients.Results: Although the fissureless technique group had longer operation time than the traditional technique group (P=0.0045), there was no significant inter-group difference about blood loss (P=0.85), occurrence rate of intraoperative massive bleeding (P=0.6) or conversion rate to thoracotomy (P=0.31). According to postoperative results, there was no significant inter-group difference in duration of chest tube drainage (P=0.56), length of postoperative hospital stay (P=0.14), or morbidity rate (P=0.16). No mortality occurred in either group.Conclusions: A thoracoscopic fissureless lobectomy is feasible and safe, and useful to avoid postoperative air-leakage in patients with dense fissures.

Editorial comment on ‘Fissureless fissure-last video-assisted thoracoscopic lobectomy for all lung lobes: a better alternative to decrease the incidence of prolonged air leak?’

“…We agree with Igai et al (13), for lower lobectomies when the bronchus is resected before the PA, careful attention is necessary to the PA in order to avoid catastrophic injury.…”

Video-Assisted Thoracoscopic Surgery vs Thoracotomy for Non-Small Cell Lung Cancer Greater Than 5 cm: Is VATS a feasible approach for large tumors?

“…Liang et al analyzed 133 patients with a tumor larger than 5 cm and compared VATS with open lobectomy. In this study, the VATS group had shorter operative duration and less intraoperative bleeding but there wasn't seen any significant difference in terms of mean drainage time, postoperative length of stay, and survival [ 12 ]. Nakano et al retrospectively analyzed 68 patients who underwent anatomical pulmonary resection for primary lung cancer of > 5-cm diameter and reported significantly less intraoperative bleeding and shorter length of postoperative hospital stay in the VATS group.…”

The learning curve of thoracoscopic surgery in a single surgeon and successful implementation of uniportal approach

“…Alternatively, it may reflect the decision to use a fissureless technique in patients with a dense fissure. Several procedures have been introduced to reduce the rate of postoperative PAL, and at our hospital use of the fissureless technique during thoracoscopic lobectomy achieved this (18,19). However, a highly experienced surgeon is required because the surgical steps are different from those of the conventional technique, in which the pulmonary arteries are dissected and exposed at the fissure.…”